Este trabalho discute o papel da avaliação tecnológica, e da análise custo-efetividade em particular, no planejamento e gerência da difusão e incorporação (financiamento) de tecnologias de saúde, com base em evidências científicas, no SUS. Explicita o papel da avaliação tecnológica na elaboração de diretrizes clínicas baseadas nas evidências científicas, importantes na melhoria da qualidade e eficiência da atenção no SUS. Introduz os objetivos, requerimentos e limitações de metodologias utilizadas pela avaliação tecnológica para a análise e síntese do conhecimento relativo aos efeitos sobre a saúde e outras implicações do uso das tecnologias. Enfatiza a importância, para a análise custo-efetividade, da evidência relativa ao benefício, da utilização do custo econômico (incremental), ao invés do custo contábil, e da explicitação do(s) ponto(s) de vista da análise. É apresentada uma análise preliminar dos processos de difusão e incorporação de tecnologias/procedimentos no SUS, apontando-se as possibilidades do aperfeiçoamento desses processos, bem como do processo de elaboração de diretrizes de conduta clínica, a partir da implementação de atividades de avaliação tecnológica adequadamente elaboradas, tomando os pontos de vista do governo e da sociedade.

This article briefly presents the target factors and methods for summarizing evidence employed in a technological evaluation, as well as the underlying logic in their elaboration and utilization in the field of public health. The example is post-menopausal osteoporosis, analyzing the current timeliness of disseminating bone densitometry and technologies to combat osteoporosis in Brazil Available studies on the effects of the respective technologies were reviewed according to the recommended methodology in order to produce a synthesis of the scientific evidence, updated and applied in Brazil. Preliminary cost-effective analyses of different alternatives for intervention (as compared to traditional care) are presented, considering women in and around menopause and at 65 years of age. Despite the optimistic hypotheses, the incremental cost estimates per averted fracture were high, all above R$ 10,000 for any of the various intervention alternatives, as compared to a mean cost of fractures treated by traditional care estimated at less than R$ 2,000, suggesting that the implementation of any of the target alternatives in the SUS would be questionable according to both efficiency criteria in the use of resources as well as equity.

This paper focuses on the issue of the extent to which the present mainstream risk adjustment (RA) methodology for measuring outcomes is a valid and useful tool for quality-improvement activities. The method's predictive and attributional validity are discussed, considering the confounding and effect modification produced by medical care over risk variables' effect. For this purpose, the sufficient-cause model and the counterfactual approach to effect and interaction are tentatively applied to the relationships between risk (prognostic) variables, medical technology, and quality of care. The main conclusions are that quality of care modifies the antagonistic interaction between medical technologies and risk variables, related to different types of responders, as well as the confounding of the effect of risk variables produced by related medical technologies. Thus, confounding of risk factors in the RA method, which limits the latter's predictive validity, is related to the efficacy and complexity of associated medical technologies and to the quality mix of services. Attributional validity depends on the validity of the probabilities estimated for each subgroup of risk (predictive validity) and the percentage of higher-risk patients at each service.

O entendimento do formato da Intervenção Familiar citada pelos ensaios clínicos controlados na condição esquizofrenia foi o foco de nossa investigação aqui relatada. Procedemos a uma busca sistemática na base de dados MedLine e elaboramos a compreensão da fundamentação teórica das práticas descritas para avaliar a heterogeneidade clínica das intervenções que são objeto de estudo dos ensaios que resgatamos. Descrevemos um modelo denominado "pragmático", que apresenta fragmentos de técnicas, sem princípios de base ou técnicas derivadas de teorias; outro modelo cuja ênfase do trabalho é na mudança comportamental; e por fim um modelo cognitivo comportamental, que privilegia a abordagem cognitiva. Fazemos considerações sobre os conceitos de Emoção Expressa (EE) e Sobrecarga Familiar, subjacentes aos modelos comportamental e cognitivo comportamental na Intervenção Familiar para Portadores de Esquizofrenia. Consideramos que esse modelo, que privilegia um maior entendimento do familiar acerca da esquizofrenia, com a devida adequação devido às especificidades culturais nacionais, deve ser investigado para a utilização nos CAPS do Brasil.

This study aimed to assess quality of obstetric care for preterm labor patients, using referents, indicators, and standards derived from scientific evidence, focusing on antenatal corticotherapy. Available meta-analyses and randomized controlled trials were examined to establish referents, defining indicators and estimating process and outcome standards for the present study. Data from hospital discharge summaries of seven public maternity hospitals in Rio de Janeiro were analyzed. The standard of process used was 100%. It was not possible to estimate outcome standards, since the necessary adjustment for gestational age was not feasible. Utilization of antenatal corticotherapy in the present study was very low, about 4% and 2%, considering patients up to 33 weeks and 6 days and 36 weeks and 6 days, respectively. Failure to use antenatal corticotherapy when formally indicated deserves attention by health planners and managers, considering: a) the ease in incorporating such a technology, in contrast to the adequate incorporation of special/intensive neonatal care; b) benefits and costs associated with this technology compared to those of delivering neonatal care to premature babies.

(logrank and Peto, p=0.02) and the presence of functional arteriovenous fistulae p=0.0099; Peto, p=0.0090

Validation of outcomes of different levels of neonatal care through the analysis of the relationship between process and outcome of care was attempted as part of an effectiveness study and quality assurance programme. Adequacy rates and outcome measures were calculated for second- and third-level units and centres according to the babies' level of risk. Differences in adequacy rates were apparently influenced by the differential distribution of babies by care level sectors among maternity centres. The comparison of mortality rates for "treated" and "untreated" subgroups did not show higher mortality rates for the "untreated" subgroups. This finding could be related to the phenomenon of "confounding by indication". Consistency of differences in average rates of adequacy with differences in general outcomes was observed for most subgroups analysed; lack of consistency could be related to low effectiveness. Indications of low effectiveness related to secondary and more so to tertiary level technologies were observed. The study approach was found more useful for comparisons made at the level of maternity services as a whole, where "confounding by indication" does not operate than at the level of sectors.

The objective of this study was to assess quality of care for premature labor at public maternity facilities in Rio de Janeiro, Brazil, using referents, indicators, and standards of care derived from scientific evidence. The standard utilized in the process analysis for use of betamimetic tocolytics was 100%, considering the related referents. For outcome analysis, the standard applied was the occurrence of premature delivery in 11% of patients within 24 h and in 24% of patients (referent) within 48 h of hospital admission. Use of tocolytics was observed in 18.7% of patients admitted in premature labor. At gestational age from 28 weeks to 33 weeks and 6 days, especially critical for neonatal survival, tocolytics were used in 32.6% of patients. Premature birth occurred in 59% of patients within 24 h and in 64% within 48 h. These outcomes were consistent with the low rate of utilization of tocolytics. Effectiveness of care for preterm labor measured by rate of premature birth was low. Results of the corresponding process and outcomes analysis were consistent.